Testing an empirically-supported family based therapy (MDFT): USA vs. The Netherlands

1. Testing an empirically-supported family based therapy (MDFT): USA vs. The Netherlands H. Liddle, C. Rowe Center for Treatment Research on Adolescent Drug Abuse University of Miami Miller School of Medicine H. Rigter Erasmus MC, Rotterdam V. Hendriks Parnassia Research Centre, The Hague

2. NIDA ‘parent grant’Training clinicians in empirically based family therapyPI: Dr. Howard LiddleNIDA grant number IRD1 DA016969

3. Topics to be covered in our presentation • Our collaboration is not fake • Our proposal does not come out of the blue. It has strong support. • Our proposal fits priorities from the Call for Proposals • Major comments by the reviewers • The parent grant • Supplement study: Some methodological issues • Added value of U.S. – Dutch collaboration

4. Our collaboration: Some history • In 2000, five European countries (B, F, G, N, S) joined forces to end ideological conflict about cannabis by doing research • On February 2002, joint meeting in Brussels with scientists from all over the world • April 2003, joint Cannabis Research Action Plan of the five countries

5. Priorities Cannabis Research Action Plan • Assess the importance of age of onset of cannabis use • Cannabis dependence: assessment and course • Relationship with mental health • Treatment trial (emphasis on youth)

6. Chosen from literature review: MDFT • 5 Completed RCT’s (generally 1 year follow-up) • MDFT more effective than (a) group counselling, (b) group family sessions, and individual CBT • MDFT more effective than residential treatment • Effective in white, black and Latino adolescents • Effective in adolescents referred by Justice, schools, or self-referred • Effective on multiple outcomes: drug use, externalizing and internalizing symptoms, delinquency, school performance

7. Conclusions drawn in the Cannabis Research Action Plan • MDFT is the best established treatment • Pilot study (INCANT) September 2004 – May 2005: European therapists trained in MDFT, one per country (supervisors) • If MDFT is feasible, a main study (RCT) will be considered (2005 – 2008)

8. And that’s where our collaboration began • In past 1.5 years, many visits to and from Miami • Intensive contacts between CTRADA, Erasmus MC, and treatment centers • E-mails: almost daily. Calls: weekly. Listserve • Cannabis Questionnaire; Addiction Treatment Inventory; Treatment Contact Logs; 8 Video and Audio Taped translated treatment sessions

9. How about the INCANT main study? We now know that MDFT is feasible in the Netherlands

10. The RCT proposed to NIDA and ZonMw is the INCANT main study in the Netherlands. • No such in-depth study is foreseen in the other four countries in the immediate future, because of: 1. Treatment conditions being too different from U.S.-based settings 2. Insufficient support from treatment centers 3. Supervisors scoring below standard on measures of MDFT compliance, adherence, and competence (Scores of Dutch supervisor were excellent.)

11. Conclusions so far • Our collaboration has real substance. Much preliminary work has been done. • Dutch conditions for the proposed supplement study are good (excellent supervisor, eager therapists in favor of MDFT, managerial and political support)

12. Overall judgment of reviewers: Positive – Very Positive Major comments • Is there really a need for adolescent treatment in the Netherlands for cannabis use disorder plus associated problems? • What is the focus of MDFT treatment? What is the outcome? Just cannabis use outcomes or more? • Enough power to assess expected outcomes? Long enough follow-up?

13. Treatments for adolescents: Some notes • Cannabis is not a (lasting) problem for most users • However, for some users it is. Especially when they: • Start using the drug at a young age (true in the Netherlands) • Have other problems as well (true in the Netherlands) • Additional complication may be: increasing potency of cannabis

14. Comment 1: Adolescents • Our proposal targets 3 key issues in the Call for Proposals: Youth, Cannabis, Treatment • The Netherlands lacks facilities for evidence-based treatment of adolescents with cannabis use disorder (among other behavioral problems; high co-morbidity) • Adolescents are especially sensitive to the development of resilient cannabis use disorder

15. CANNABIS How many stop their use entirely on their own in 5 years time?

16. Associations of mental disorders with substance use disorders

17. Comment 1: Adolescents (Continued) • Age of first use of cannabis has gone down • Treatment demand has increased • Unmet treatment need worrying to Government and treatment centers • Concentration of THC has increased

18. Comment 2What is the focus of MDFT treatment? What is the outcome? • Primary outcome: cannabis and other substance use • Secondary outcomes: less externalizing and internalizing symptoms, better family and school functioning, less delinquency

19. Pieces of MDFT approach • MDFT intervenes into multiple systems of development and influence (family, peers, school, etc.). Four domains of attention/intervention: • Adolescent • Parent(s) • Family • Extra-familial

20. Pieces of MDFT approach • Problems are multidimensional • Multidimensional problems require multi-component, multi-focus interventions • All those domains/systems may help the adolescent to overcome his or her problems

21. Howard, I would include here some slides re. Comment 3 by reviewers: power, length of follow-upAnd also some slides on the parent study, showing proficiency in implementation research

22. Wrapping up • Our collaboration is real • Much preliminary work has been done • Proposal fits priorities of the Call • The Netherlands = excellent site for testing MDFT outside the USA • We have addressed the comments by the reviewers (who were positive – very positive) • Added value (see last slide)

23. Conditions favoring a collaborative implementation trial of MDFT in the Netherlands • Strong commitment from the two centers in The Hague: management, trained supervisor, team of dedicated therapists eagerly waiting to be trained • Strong collaboration between the two centers • Treatment philosophy similar to that of CTRADA. Treatment As Usual can be standardized.

24. Conditions favoring a collaborative implementation trial of MDFT in the Netherlands • Regular flow of adolescents and parents/families demanding treatment (from all over the country; present waiting list will be made undone shortly) • Parents willing to join treatment • Training materials ready (no translation needed) • National Government in favor (might donate additional funds)

25. FINALLY: Added value of a NIDA – ZonMw trial • Opportunity to establish the effectiveness of MDFT outside the USA • Broader experience with practical applicability (implementation) of MDFT, across more settings and in more ethnic groups (in the Netherlands including Mediterranean and Caribbean youth: 30% of clients) • In the Netherlands, badly needed addition to treatment repertoire • Emphasis on multidimensionality of problem behaviors in youth • Much appreciated collaboration between research groups from different settings